In order to provide better care to older adults living with dementia, the senior living industry must adapt and be ready for the the Centers for Medicare and Medicaid Services’ (CMS) GUIDE model rollout this year.
The GUIDE model, which was announced in 2023, aims to help those with dementia stay in their homes longer and stay healthier by offering training for in-home caregivers and around-the-clock support. It also tests a new form of payment for participating providers to coordinate care for patients.
“It has very disruptive potential, and I would argue it’s going to change the landscape of care and services for individuals with dementia, regardless of what happens to this one particular program,” said ATI Advisory CEO Anne Tumlinson during a Ziegler webinar on GUIDE for life plan communities. “It’s the beginning of a new way of thinking about paying for things that we haven’t paid for before in order to meet the long-term care needs of the population with dementia and, in the future, those who have other kinds of functional and cognitive decline.”
Senior living providers have an ‘excellent opportunity’ with GUIDE
Experts have said the GUIDE model could be “a game-changer for the industry,” in the words of James Lee, co-founder and CEO of memory care community Bella Groves, to evolve the business model of senior living going forward.
CMS data shows that 8% of the Medicare fee-for-service population has a dementia diagnosis, which represents between 25% and 50% of people living with dementia while others are not Medicare beneficiaries. Within that 8%, the average Medicare Part A and Part B spending is $35,000 annually.
“If there’s any population on the whole that is likely to need long-term services and supports over their lifetime, it’s going to be this population,” Tumlinson said. “We look at those who have long-term care spending over their lifetime, and we look at the distribution, what we see is a significant proportion of them use very little and then die.”
This is the heart of the issue GUIDE is attempting to solve: Bringing dementia and long-term care services to more older adults living with cognitive decline. By 2040, CMS data projects that nearly half of the older adult population will be over the age of 75.
Tumlinson said the GUIDE model was a “fairly major turning point” in the way that CMS interacts with the caregiver and not the typical Medicare beneficiary of the past. At the center of the model is care coordination and care management for people living with dementia, something Tumlinson called “pretty unique and new.”
Memory care operators, known as sub-participants in the GUIDE program, are eligible for two types of payments with senior living organizations partnered with GUIDE model participants to meet CMS’ overarching goals. Over the course of this year, senior living companies are eligible for an “infrastructure payment” in the next 12 months to get the GUIDE program implemented by July 2025.
Subsequently, GUIDE model participants will receive a per-member monthly payment for each of the beneficiaries that providers are aligned with in the GUIDE program, with repayment also being tied to the “complexity of the individual” receiving dementia care in GUIDE. There will also be a $2,500 respite care amount available to providers for family caregivers associated with older adults living with dementia.
At Home Harmony CEO Will Saunders said life plan communities and other senior living providers must be ready for residents getting information on GUIDE, urging organizations to engage with residents and those living at home and receiving care.
Informing residents, being ‘proactive’ ahead of rollout
At Home Harmony, which provides in-home care for residents through a private provider network, is working with trade association LeadingAge and other nonprofit entities to “get prepared” for the rollout of the GUIDE model.
Participants in the GUIDE model must deliver on various elements in order to receive repayment: three comprehensive health assessments, medication management, ongoing care planning, monitoring and coordination, and caregiver support.
“I think this is really innovative and also something that senior living should really think through. A significant proportion of the care model is really meant for that caregiver specifically,” Saunders said. “There’s an opportunity for a [senior living] resident to enroll in a GUIDE participant, and unless you’re proactive, that could be located anywhere in the country.”
Saunders added that senior living providers have an opportunity to “supply a consistent level of service” and care.
In a change in how participants can contact and market to patients and caregivers in the GUIDE model, CMS will allow organizations to reach directly out to caregivers and families regarding GUIDE enrollment, regardless of location, and Saunders urged senior living providers to have information ready to participate—if equipped.
“This is coming, and it’s going to be transformative in the industry because the families and the residents themselves are going to be embracing this model, and that’s what we’re seeing on the ground today,” Saunders said. “We want to get proactive.”
That proactivity looks like having a “toolkit” of letters and communications ready to send to families and residents informing them about GUIDE, and supplying information on enrollment into the program, Saunders said.
“I think some of the best practices are to really make sure that you’re educating your residents,” Saunders said. “Then you’re partnering with somebody who understands how senior living actually works.”